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Surgery > Anaesthetics and peri-operative care > Flashcards

Anaesthetics and peri-operative care Flashcards

1
Q

What parts of a cardiovascular history are particularly important in a pre-op assessment?

A

Previous MI - increased risk of further infarction
Poorly controlled hypertension - risk of ishcaemic event
Heart failure - increased morbidity and mortality
Angina frequency and severity

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2
Q

How is an airway assessmed pre-operatively?

A 
Is patient overweight
How far can their mouth open
Do they have a short neck or small mouth
Is there any soft tissue swelling
Any reduced flexion/extension of cervical spine
Mallampati criteria
Thyromental distance
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3
Q

What is an ASA grade 1?

A

Normal healthy individual without systemic disease

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4
Q

What is an ASA grade 2?

A

Person with mild to moderate systemic disease that doesn’t cause any limitation in activity eg treated hypertension

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5
Q

What is an ASA grade 3?

A

Severe systemic disease imposing functional limitation on activity

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6
Q

What is an ASA grade 4?

A

Incapacitating systemic disease which is a constant threat to life eg unstable angina

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7
Q

What is an ASA grade 5?

A

Moribund patient unlikely to survive 24 hours with or without surgery

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8
Q

What pre-op investigations should be done for minor surgery?

A

U&Es in older people or ASA3+ if at risk of AKI

ECG if over 40 or ASA 3+

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9
Q

What pre-op investigations should be done for intermediate surgery?

A

FBC is renal or cardiovascular disease
U&Es if at risk of AKI
LFTs and clotting if liver disease or on anticoagulants
ECG if cardiovascular, renal disease, or diabetes or ASA3+
?ABG

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10
Q

What pre-op investigations should be done for major or complex surgery?

A 
FBC
U&Es
Clotting and LFTs
ECG in most people
?Cross match/group and save
?ABG
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11
Q

When is a group and save and when is a cross match done before surgery?

A

Group and save is if there maybe some blood loss but it is not routine for this procedure eg in appendicectomy
Cross match if blood loss is anticipated

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12
Q

Give 3 examples of minor surgery?

A

Release of peripheral nerve entrapment at the wrist
Tooth extraction
Excising skin lesion
Drainage of middle ear

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13
Q

Give 3 examples of intermediate surgery

A

TOnsillectomy
Excising varicose veins
Arthroscopy
ECT

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14
Q

Give 3 examples of major surgery

A 
Total joint replacement
Lung surgery
THyroidectomy
Organ transplantation
Excision of colon
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15
Q

What are the body’s requirements for water and electrolytes?

A

30ml/kg/day of water
Roughly 1-2mmol/kg.day of sodium, potassium and chloride
50-100g per day of glucose

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16
Q

How is fluid resuscitation done?

A

500ml boluses in 15 mins of either Hartmann’s or normal saline, up to 2 litres as required

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17
Q

How does the composition of losses from vomit differ from plasma and what is the importance of this?

A

Has lower sodium and higher potassium and chloride. This means it puts pt at risk of hypochloraemic hypokalaemic alkalosis. This should be adjusted for in fluid management

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18
Q

How do fluid losses from sweating impact on fluid management decisions?

A

Sweat has relatively low electrolytes so can predispose to hypernatraemia. Be careful not to overload with sodium

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19
Q

How can post-op pain be minimised?

A

Pre-op counselling
Pre-emptive analgesia peri-operatively
Post-op analgesia

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20
Q

Name 3 methods of peri-operative pre-emptive analgesia?

A 
IV long acting analgesia
Local anaesthetic infiltration at wound edges
Regional nerve blocks
Epidural
IV/suppository NSAID before waking
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21
Q

What monitoring should be done in a patient with an epidural?

A

Look out of severe hypotension and respiratory depression (signs of toxicity)

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22
Q

What are the benefits of PCA?

A

Excellent continuous pain relief
Minimal sedation
Minimal respiratory depression

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23
Q

Give 5 complications that may manifest as excessive post-op pain

A 
Compartment syndrome
Haematoma
Infection
DVT
MI
Acute limb ischaemia
Haemorrhage
Anastamotic leak
Biliary leak
Abscess
Obstruction/ileus/constipation
Urinary retention
Bowel ischaemia
#NOF if fall
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24
Q

How should mild-moderate post-op pain be managed?

A

Paracetamol
Cocodamol
Mild oral NSAID eg ibuprofen

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25
Q

How should moderate post-op pain be managed?

A

Paracetamol
Codeine/dihydrocodeine
Oral/suppository stronger NSAID eg diclofenac

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26
Q

How should moderate-severe post-op pain be managed?

A

Moderate opiate eg oxycodone or tramadol
IV NSAID eg diclofenac
Oral slow release morphine
PCA morphine/diamorphine

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27
Q

Give 5 causes of post-op shortness of breath

A 
Acute bronchopneumonia
Aspiration
Lobar collapse
Pneumothorax
PE
Atelectasis
ARDS
Abdominal distension
Cardiac failure
Hyperventilation
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28
Q

Give 5 conditions associated with the development of ARDS

A 
Radiation pneumonitis
Lung contusion
Sepsis
Severe acute pancreatitis
Near-drowning
Aspiration of gastric contents
Inhalation of corrosive materials
Fat, air, or amniotic fluid embolism
Multiple trauma with shock
Major head injury
Massive blood transfusion
DIC
Eclampsia
Cardiopulmonary bypass
Severe allergic reactions
Drug overdose
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29
Q

How does atelectasis occur?

A

Mucus is retained in the bronchi causing bronchial obstruction. Alveoli supplied by those bronchi collapse as air in them is reabsorbed
Collapse of lung segments with reduced ventilation
Secondary infection may occur

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30
Q

Give 3 patient factors increasing the risk of atelectasis

A 
Obesity
Pregnancy
Smoker
Muscular weakness
Difficulty coughing
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31
Q

Give 3 treatment factors that increase the risk of developing atelectasis

A 
Opiates
Wound pain
NG tube
Irritant anaesthetic drugs
Atropine
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32
Q

Give 5 features of atelectasis

A 
Dyspnoea
Tachycardia
Pyrexia
Cyanosis
Painful cough
Reduced chest expansion
Basal dullness
Reduced air entry
Crepitations
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33
Q

How does atelectasis appear on an x ray?

A

Opacity

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34
Q

How is atelectasis managed?

A

Extensive chest physiotherapy
Ensure adequate analgesia to aid mucus clearance
Treat any secondary infection

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35
Q

What is acute respiratory distress syndrome?

A

Interstitial oedema and reduced ling compliance as a result of a lung injury. Causes large VQ mismatch and respiratory failure

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36
Q

How does ARDS occur?

A

Insult to lung raises the pulmonary capillary permeability, causing exudate of fluid into alveolar interstitium causng interstitial oedema and reduced lung compliance and so reduced ventilation
Damage to alveolar cells also causes alveolar spaces to fill with fluid
There is a VQ mismatch causing a large shunt
On recovery, there is interstitial fibrosis

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37
Q

What are the clinical features of ARDS?

A

Rapid, shallow breathing
Scattered crepitations
Reduced PO2

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38
Q

What is the appearance of ARDS on chest x ray?

A

Progresses from normal to increase in interstitial markings to white out

39
Q

How is ARDS managed?

A 
ICU bed
Ventilation with PEEP
Monitor right atrial pressure
TOE to monitor cardiac output
Loop diuretics or haemofiltration to maintain negative fluid balance
40
Q

Give 5 causes of post-op tachycardia

A 
Anxiety
Pain
Atrial fibrillation
Atrial flutter
Infection
Circulatory disturbance
Thyrotoxicosis
Hypovolaemic shock
Haemorrhage
Dehydration
Cardiac failure
MI
Anastamotic leak
41
Q

Give 5 causes of post-op pyrexia

A 
Drug reaction
Transfusion reaction
Thyrotoxic crisis
Phaeochromocytoma
Malignant hyperthermia
Malaria
Central or peripheral line infection
UTI
Wound infection
Pneumonia
PE
Haematoma
Anastamotic leak 
DVT
42
Q

What drugs commonly cause PONV?

A

Opiates
Erythromycin
Metronidazole

43
Q

Give three causes of immediate PONV

A 
Anxiety
Gut handling
Vestibular stimulation
Oropharyngeal stimulation
Hypotension
Hypoxia
Pain
44
Q

What features of PONV may indicate bowel obstruction?

A

If there’s sustained vomiting more than 2 days post-op

45
Q

What are the two main causes of post-op oliguria?

A

Urinary retention

Reduced urinary production

46
Q

Give 3 causes of post-op urinary retention

A

Pre-existing outlet obstruction
Difficulty with passing urine supine
Difficulty passing urine without privacy
Overfilling of bladder due to accumulation of large urine volume during operation
Transient disturbance of neurological control
Wound pain inhibiting abdominal muscle contraction
Specific surgery predisposing to retention
Constipation

47
Q

Which surgeries increase the risk of post-op urinary retention?

A

Abdominoperineal rectal resection

Bilateral inguinal hernia repair

48
Q

How is post-op urinary retention managed conservatively?

A

Adequate analgesia
Encourage mobility to be able to use commode/bottle or wheel to bathroom and give time alone
Encourage bowel movements

49
Q

How is post-op oliguria managed?

A

Conservatively
Catheterisation
Flush catheter if already in situ

50
Q

What examination findings suggest urinary obstruction?

A

Palpable suprapubic mass

Dull to percussion

51
Q

What are the common causes of reduced post-op urine production?

A

Reduced renal perfusion due to hypovolaemia
Hypotension
Cardiac failure
MI

52
Q

How is reduced post op urine production managed?

A

Catheterisation to monitor output

Fluid challenge if cause thought to be hypovolaemia

53
Q

What are the two types of neuromuscular blockers?

A

Depolarising

Non-depolarising

54
Q

Give an example of a depolarising neuromuscular blocker and explain its action

A

Suxamethonium

Causes depolarisation and then blocks repolarisation causing paralysis until is hydrolysed by cholinesterase

55
Q

When is suxamethonium used?

A

RSI

Urgent tracheal intubation, esp if at high risk of aspiration

56
Q

Give 3 side effects of suxamethonium

A

Limb girdle pain
Malignant hyperpyrexia
Prolonged apnoea if deficient in (pseudo)cholinesterase
Raised intraocular pressure
Histamine release
Rise in potassium. Can be large in eg burns, crush injuries

57
Q

Give an example of a non-depolarising neuromuscular blocker and explain its action

A

Atracurium

Blocks ACh’s access to nicotinic receptors so cannot cause depolarisation

58
Q

When are non-depolarising neuromuscular blockers used?

A

Non-urgent tracheal intubation

Maintenance of muscle relaxation after suxamethonium

59
Q

How is neuromuscular blockade reversed?

A

By giving anticholinesterase eg neostigmine

60
Q

Name 3 IV anaesthetic agents

A

Propofol
Etomidate
Sodium thiopentone
Ketamine

61
Q

What are the main benefits of propofol?

A

Rapid acting
Rapidly wears off
Metabolites don’t accumulate so can be used for maintenance

62
Q

Give 3 side effects of propofol

A 
Involuntary movements
Reduced cerebral blood flow
Myocardial depression
Pain on injection
Hypotension
Ventilatory depression
63
Q

When is sodium thiopentone used?

A

For rapid sequence induction

64
Q

What are the disadvantages of sodium thiopentone?

A

Causes significant myocardial depression

Rapidly accumulates so can’t be used for maintenance

65
Q

Which IV anaesthetic agents are safe in cardiovascular instability?

A

Etomidate

Ketamine

66
Q

What is a major side effect of etomidate?

A

Adrenal suppression

67
Q

Name three factors that increase MAC

A 
Children
Chronic alcohol use
Chronic opioid use
Hyperthermia
Hyperthyroidim
Hypernatraemia
Raised catecholamines
68
Q

Name three factors that reduce MAC

A 
Old age or neonates
Hypothermia
Hypothyroidism
Hyponatraemia
Acute alcohol use
Acute TCA use
Acute opioid use
Acute benzodiazepine use
Pregnancy
Anaemia
Lithium
69
Q

Name two inhaled anaesthetic agents

A

Isoflurane
Desflurane
Sevoflurane

70
Q

Which inhaled anaesthetic agents allow rapid changes in depth of anaesthesia and why is this??

A

Desflurane
Sevoflurane
Have low solubility so changes in concentration rapidly change the depth and affect on brain

71
Q

What is the benefit of adding adrenaline to a local anaesthetic?

A

Cause vasoconstriction reducing rate of absoprtion, reducing toxicity and increasing duration of action

72
Q

What is the difference between APTT and PT?

A

APTT measures intrinsic pathway (9, 11, 12 and 10)

PT measures extrinsic pathway (1, 2, 7, 5, 10)

73
Q

What is the action of heparin?

A

Activates antithrombin 3 to break down clots

74
Q

How is the action of heparin reversed?

A

Protamine sulphate

75
Q

What are the side effects of heparin?

A

Bleeding
Osteoporosis
Hyperkalaemia
Thrombocytopenia

76
Q

How is heparin monitored?

A

Unfractionated monitored with APTT

77
Q

What is the action of warfarin?

A

Inhibitis vitamin k so reduces levels of vit K dependent factors (10, 9, 7, 2) and protein C

78
Q

Give 3 side effects of warfarin

A

Purple toes
Skin necrosis
Haemorrhage
Teratogenesis

79
Q

What is the thromboprophylaxis regime for general surgery patients?

A

5000 units sc dalteparin night before surgery or intra-operatively
Below knee AES
Intermittent pneumatic compression boots in theatre

80
Q

What is the thromboprophylaxis regime for vascular surgery patients?

A

5000 units sc dalteparin night before surgery or intraoperatively unless undergoing neck surgery, eg CEA
Intermittent pneumatic compression stockings on individual basis

81
Q

What is the thromboprophylaxis regime for endocrine surgery patients?

A

Below knee AES

82
Q

Name 3 contraindications to the use of LMWH

A

Recent cerebral haemorrhage
Haemophilia
Severe hypertension
Acute bacterial endocarditis

83
Q

Give 3 contraindications to the use of anti-embolic stockings

A 
Peripheral arterial disease
Peripheral neuropathy
Fragile skin
Cardiac failure
Pulmonary oedema secondary to congestive heart failure
Severe leg oedema
84
Q

Name 3 benefits of surgical antibiotic prophylaxis

A

Reduces incidence of surgical site infections
Minimises affect on patients host defences
Reduces adverse effects
Reduces effects on patient’s normal bacterial flora

85
Q

What antibiotic prophylaxis is used in vascular surgery?

A

3 doses of co-amoxiclav or teicoplanin and gentamicin

86
Q

What antibiotic prophylaxis is given in abdominal surgery?

A

If upper GI, coamoxiclav or teicoplanin + gentamicin

If lower, metronidazole +/- gentamicin

87
Q

Name two operations that are particularly at risk of post-op haemorrhage

A

THyroidectomy
Parathyroidectomy
Angiography
Laparoscopic surgery with pfannenstiel incision

88
Q

What is the cause of reactive post-op bleeding?

A

Usually bleeding from a slipped ligature or a vessel that was missed due to hypotension induced vasoconstriction. Bleeding will only occur once BP normalises

89
Q

What is the main cause of secondary post-op bleeding?

A

Erosion of a vessel due to a spreading infection

90
Q

What are the 3 peak times of operative haemorrhage?

A

Primary occurs intraoperatively
Reactive occurs within 24 hours
Secondary usually occurs after 7-10 days

91
Q

What is the difference between a provoked and an unprovoked VTE?

A

Provoked VTEs are associated with a transient risk factor that can easily be removed
Unprovoked VTEs occur in the absence of a transient risk factor so there may either be no risk factor or there may be one that is persistent and not easily correctable eg cancer

92
Q

What are the clinical features of a DVT?

A

Swelling and pain in the leg
Altered skin colour and temperature
Vein distension
Tenderness

93
Q

What advice should be given to the patient after a DVT has resolved?

A

To increase walking exercise

To keep leg elevated whilst sitting

94
Q

What is post-thrombotic syndrome of the leg?

A

A complication of a DVT with chronic venous hypertension, leading to pain, swelling, dermatitis, hyperpigmentation, ulceration and lipodermatosclerosis

Surgery (4 decks)

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